Cycle 1
Health 2025-03-07 · Fire 2025-03-07
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Carmel, IN
Retreat At The Stratford, The
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
2460 Glebe St, Carmel, IN
(317) 733-9560
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
18
Certified beds
Average residents
10
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Senior Living Communities
Operator or chain grouping
Approved since
2012-01-04
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.87
Registered nurse staffing
LPN hours / resident day
1.52
Licensed practical nurse staffing
Aide hours / resident day
3.87
Nurse aide staffing
Weekend hours
6.65
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
64%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.7% |
93.6%
20.9 pts worse
|
93.4%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
24.2%
0.5 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.1%
2.4 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.8% |
81.6%
31.8 pts worse
|
81.7%
31.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
10.5%
5.2 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
79.0%
3.4 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
22.4%
3.5 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-14 · Fire 2023-03-14
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-03-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-03-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-03-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-17
C · Minimal harm
2025-03-07
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-17
C · Minimal harm
2025-03-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-17
C · Minimal harm
2025-03-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-04-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-05
C · Minimal harm
2024-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-05
F · Potential for more than minimal harm
2023-03-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-03-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-03-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-06-29
C · Minimal harm
2023-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-06-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-03-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-04-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-04-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-03-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$0
2025-03-27
Payment Denial
Payment Denial · denial start 2025-06-27 · 6 days
6 day denial
Ownership
Thompson, Donald
5% Or Greater Direct Ownership Interest · Individual
Thompson, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Thompson, Joshua
5% Or Greater Direct Ownership Interest · Individual
Maxwell Group, Inc.
Operational/Managerial Control · Organization
Miller, Bradley
Operational/Managerial Control · Individual
Solito, Leo
Operational/Managerial Control · Individual
Thompson, Benjamin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Copper Trace Health & Living Community
Westfield, IN
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Majestic Care Of Carmel
Carmel, IN
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Wellbrooke Of Carmel
Carmel, IN
3-star overall rating with 2-star inspections with $15,646 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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